E-Cigarettes Use, Effects On Smoking, Risks, and Policy Implications

PU39CH13_Glantz ARI 26 February 2018 13:16
Annual Review of Public Health
E-Cigarettes: Use, Effects on

Smoking, Risks, and Policy
Implications
Annu. Rev. Public Health 2018.39:215-235. Downloaded from www.annualreviews.org
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Stanton A. Glantz1 and David W. Bareham2

1
Center for Tobacco Control Research and Education and Department of Medicine, University
of California, San Francisco, California 94143, USA; email: Stanton.Glantz@ucsf.edu
2
Lincolnshire Community Health Services NHS Trust, Louth, LN11 0EU, United Kingdom;
email: david.bareham@live.co.uk
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First published as a Review in Advance on smoking initiation, smoking cessation, cancer, cardiovascular disease, lung
January 11, 2018
disease
The Annual Review of Public Health is online at
publhealth.annualreviews.org Abstract
https://doi.org/10.1146/annurev-publhealth- Since e-cigarettes appeared in the mid-2000s, some practitioners, re-
040617-013757
searchers, and policy makers have embraced them as a safer alternative
Copyright c 2018 Stanton A. Glantz & David W. to conventional cigarettes and an effective way to stop smoking. While e-
Bareham. This work is licensed under a Creative
Commons Attribution 4.0 International License, cigarettes deliver lower levels of carcinogens than do conventional cigarettes,
which permits unrestricted use, distribution, and they still expose users to high levels of ultrafine particles and other toxins that
reproduction in any medium, provided the original may substantially increase cardiovascular and noncancer lung disease risks,
author and source are credited. See credit lines of
images or other third-party material in this article which account for more than half of all smoking-caused deaths, at rates simi-
for license information lar to conventional cigarettes. Moreover, rather than stimulating smokers to
switch from conventional cigarettes to less dangerous e-cigarettes or quitting
altogether, e-cigarettes are reducing smoking cessation rates and expanding
the nicotine market by attracting youth.
215
INTRODUCTION
Cigarettes are a highly effective way of delivering the addictive drug nicotine. They do so by
burning tobacco to create an aerosol of ultrafine particles that carries nicotine deep into the lungs,
where it is rapidly absorbed, then travels through the left heart, reaching the brain in a few seconds.
The combustion process also generates carcinogens, oxidizing agents, and other toxins. Like
cigarettes, electronic cigarettes (e-cigarettes) create an inhaled aerosol of ultrafine particles that
rapidly delivers nicotine to the brain. In contrast with cigarettes, however, e-cigarettes generate the
aerosol by heating a liquid, usually consisting of propylene glycol or vegetable glycerin, nicotine,
and flavoring agents, without any combustion (53).
Some in the health community, particularly in England, have embraced e-cigarettes as a safer
alternative to conventional cigarettes and an effective way to stop smoking conventional cigarettes
(85, 105) and have approved of their use by pregnant women (118). Despite the fact that a puff
on an e-cigarette is almost certainly less toxic than a puff on a conventional cigarette, this opti-
mistic scenario has not developed. Rather than encouraging smokers to switch from conventional
cigarettes to less dangerous e-cigarettes or quitting altogether, e-cigarettes are reducing smoking
cessation rates and expanding the nicotine market by attracting low-risk youth who would be
unlikely to initiate nicotine use with conventional cigarettes.
TYPES OF E-CIGARETTES
E-cigarettes as originally marketed in 2004, known as cig-a-likes, were developed in China as a less
dangerous alternative to conventional cigarettes (53). The early devices looked like a conventional
cigarette, often including a small light on the tip that lit when the user puffed (Table 1). These
Table 1 Types of e-cigarettes. Reproduced under the terms of the CC-BY-NC-ND license, Reference 53
Product Description Some brands
Disposable e-cigarette Cigarette-shaped device consisting of a battery and a NJOY OneJoy, Aer
cartridge containing an atomizer to heat a solution Disposable,
(with or without nicotine). Not rechargeable or Flavorvapes
refillable and is intended to be discarded after
product stops producing vapor. Sometimes called an
e-hookah.
Rechargeable e-cigarette Cigarette-shaped device consisting of a battery that Blu, GreenSmoke,
connects to an atomizer used to heat a solution EonSmoke
typically containing nicotine. Often contains an
element that regulates puff duration and/or how
many puffs may be taken consecutively.
Pen-style, medium-sized rechargeable e-cigarette Larger than a cigarette, often with a higher-capacity Vapor King Storm,
battery, may contain a prefilled cartridge or a Totally Wicked
refillable cartridge. Often come with a manual Tornado
switch allowing the user to regulate length and
frequency of puffs.
Tank-style, large-sized rechargeable e-cigarette Much larger than a cigarette with a higher-capacity Volcano Lavatube
battery and typically contains a large, refillable
cartridge. Often contains manual switches and a
battery casing for customizing battery capacity. Can
be easily modified.
216 Glantz · Bareham

early systems were generally inefficient at delivering nicotine, in part because the particle sizes of
the aerosol were too large to penetrate deep into the lungs. Newer versions feature replaceable or
refillable reservoirs and rechargeable batteries that generate smaller particles and more efficient
nicotine delivery. These refillable systems allow users to separately purchase the e-cigarette liquid
(known as e-liquid or e-juice) that contains varying levels of nicotine and comes in many different
flavors (150). Running at a higher power (temperature) not only increases nicotine delivery, but
also increases the amount of formaldehyde and other aldehydes that are naturally produced by
heating up propylene glycol or vegetable glycerin (73, 98) and other toxins produced in the e-
cigarette aerosol.
While some practitioners, researchers, and policy makers viewed e-cigarettes as a disruptive
technology (122) that would compete with the established multinational cigarette company brands,
by 2014 all the major multinational tobacco companies had entered the e-cigarette market. They
did so either by buying existing e-cigarette companies (including Ruyan, the original Chinese e-
cigarette company, which was bought by Imperial Tobacco) or by developing their own products
(128). Indeed, as part of a larger policy to keep people using recreational nicotine rather than
stopping tobacco use (8, 74), Philip Morris had developed the technology of the modern e-
cigarette by the mid-1990s (38). As with their other alternative nicotine delivery systems, they
chose not to take the product to market to avoid attracting the attention of the US Food and
Drug Administration (FDA) and possibly triggering regulation of conventional cigarettes (8, 38).
Although there continue to be independently owned “vape shops,” from economic and political
perspectives the e-cigarette business is now part of the traditional tobacco industry (33, 78).
WHY PEOPLE USE E-CIGARETTES

In the United States and many other countries, e-cigarettes are not subject to the same marketing
and promotion restrictions that apply to cigarettes (136). As a result, e-cigarette companies are
permitted to advertise on television and in mass media as well as through newer channels such as
the Internet. US e-cigarette marketing expenditures increased from $3.6 million in 2010 to $125
million in 2014 (136), which translated into rapid increases in youth e-cigarette use (discussed
below). Marketing messages echo well-established cigarette themes, including freedom, good
taste, romance, sexuality, and sociability as well as messages claiming that e-cigarettes are healthy,
are useful for smoking cessation, and can be used in smokefree environments. These messages are
mirrored in the reasons that adults and youth cite for using e-cigarettes.
Adults
Adults cite predominantly three reasons for trying and using e-cigarettes: as an aid to smoking
cessation, as a safer alternative to conventional cigarettes, and as a way to conveniently get around
smokefree laws (99, 116, 131). Importantly, most adults who use e-cigarettes continue to smoke
conventional cigarettes (referred to as dual users). In 2014 in the United States, 93% of e-cigarette
users continued to smoke cigarettes (99), 83% in France (6), and 60% in the United Kingdom
(131).
Youth
Although initial discussions within the health community about e-cigarettes focused on the po-
tential for adults to use them as an alternative to cigarettes, youth have rapidly adopted them. In
addition to the same three motivations that adults have cited for using e-cigarettes (52, 110), youth
www.annualreviews.org • E-Cigarettes: Risk and Effects on Smoking 217

a 40
35
e-cigarette use (%)

Ever cigarette or
30
E-cigarette only
25 Cigarette and e-cigarette
20 Cigarette only
15 Ever smoking
10
5
0
2004 2006 2008 2010 2012 2014
b 40
35
Current cigarette or
e-cigarette use (%)
30
E-cigarette only
25 Cigarette and e-cigarette
20 Cigarette only
15 Current smoking
10
5
0
2004 2006 2008 2010 2012 2014
Figure 1
The advent of e-cigarettes did not affect declining trends in conventional cigarette smoking. After
e-cigarettes became available, dual use of cigarettes and e-cigarettes increased, and some youth started using
e-cigarettes alone; however, these changes did not affect the declining trend in cigarette use. This pattern
was observed in both ever (≥1 puff lifetime; panel a) and current (use in past 30 days; panel b) cigarette use in
the National Youth Tobacco Survey (NYTS), including dual use with e-cigarettes (cigarettes only, light
brown; dual use, dark brown). E-cigarette-only users (orange) are at low risk of having initiated tobacco
products with cigarettes (37). E-cigarette use was assessed starting in 2011. Adapted with permission from
Pediatrics 2017 Volume 139, Issue 2, pii: e20162450. doi: 10.1542/peds.2016–2450, Copyright c 2017 by
the American Academy of Pediatrics.
are attracted by e-cigarettes’ novelty (52), the perception that they are harmless or less harmful
than cigarettes (20, 52, 109, 110), and the thousands of flavors (5, 72, 136) (e.g., fruit, chocolate,
peanut butter, bubble gum, gummy bear, among others).
As a result, youth e-cigarette use in the United States doubled or tripled every year between
2011 and 2014, and by 2014, e-cigarette use had surpassed conventional cigarette use in youth
(36, 117). At the same time that e-cigarette use was increasing, cigarette smoking among youth
declined (9, 68), leading some to suggest that e-cigarettes were replacing conventional cigarettes
among youth (1, 80, 130) and are contributing to declines in youth smoking (84, 108, 111, 123).
At least through 2014, however, e-cigarettes had no detectable effect on the decline in cigarette
smoking among US adolescents (37) (Figure 1).
Whereas most of the youth who reported smoking cigarettes in the past 30 days (including dual
users of cigarettes and e-cigarettes) in 2011–2014 have demographic and behavioral risk profiles
(based on 2004–2009 data) consistent with smoking cigarettes, the risk profiles of the remaining
e-cigarette-only users (about 25% of e-cigarette users) suggested that these individuals would have
been unlikely to have initiated tobacco product use with cigarettes (37). These national results are
consistent with regional US studies that also found that e-cigarette-only users display a lower risk
profile than do cigarette smokers for smoking cigarettes (14, 24, 93, 143). Consistent with this

statement is that, in 2015, in the United States, 40% of 18–24-year-old current e-cigarette users
had never smoked conventional cigarettes (27).
This rapid increase in e-cigarette-only use among youth and young adults is of concern
because youth are more susceptible to developing nicotine dependence than are adults (136). In
addition, nicotine has adverse effects on brain development, including that of developing fetuses
(41, 134, 136).
E-CIGARETTES AS A GATEWAY TO CIGARETTE SMOKING

A national cross-sectional study of Korean adolescents based on 2011 data was the first evidence
that e-cigarette use was associated with higher cigarette use in youth (77). As with adults, dual use
was the dominant pattern. The odds of being an e-cigarette user were 1.58 times [95% confidence
interval (CI) 1.39–1.79] higher among students who had made an attempt to quit than for those who
had not. It was rare for students who had formerly smoked but were no longer using cigarettes
to be current e-cigarette users [odds ratio (OR) = 0.10; 95% CI 0.09–0.12]. A subsequent US
cross-sectional study of data collected in 2011 and 2012 found similar results (35). As in Korea
(77), current cigarette smokers who had ever used e-cigarettes were more likely to intend to quit
smoking within the next year (OR = 1.53; 95% CI 1.03–2.28) but were less likely to have stopped
smoking (OR = 0.24; 95% CI 0.21–0.28). The same US study also found that e-cigarette use was
associated with progression from experimentation with cigarettes to established smoking. Among
cigarette experimenters (youth who had smoked at least 1 puff of a cigarette), ever e-cigarette
use was associated with higher odds of becoming an established smoker (smoking 100 cigarettes;
OR = 6.31; 95% CI 5.39–7.39) and with current cigarette smoking (smoking 100 cigarettes plus
smoking in the last 30 days; OR = 5.96; 95% CI 5.67–6.27).
Such cross-sectional data, however, do not allow investigators to draw causal conclusions be-
cause they represent a snapshot in time that does not reveal whether the e-cigarette or the con-
ventional cigarette use came first. Reaching a causal conclusion requires longitudinal data where
the same people are followed over time. As of February 2017, 9 longitudinal studies were quanti-
fying the effect of starting tobacco use with e-cigarettes on progression to smoking conventional
cigarettes (119). These studies all started with youth who had never smoked a cigarette, then
compared subsequent smoking between youth who did and did not use e-cigarettes at baseline.
Adjusting for demographic, psychosocial, and behavioral risk factors for cigarette smoking, the
odds of subsequent cigarette smoking were quadrupled among e-cigarette users (Figure 2).
In sum, e-cigarettes are expanding the tobacco epidemic by bringing lower-risk youth into
the market, many of whom then transition to smoking cigarettes. The 2015 US National Youth
Tobacco Survey (117) suggests that this process may be starting. The small decline in smoking
among middle-school students between 2014 and 2015 (2.5% to 2.3%) and the small increase
in smoking among high school students (9.2% to 9.3%) are consistent with the observation that
youth who initiated nicotine use with e-cigarettes (i.e., in 2014) are more likely to be smoking
cigarettes a year later.
E-CIGARETTES AND SMOKING CESSATION

Determining how to assess the effects of e-cigarettes on smoking cessation has been one of the
most contentious aspects of the debate over e-cigarette use. In contrast with nicotine replacement
therapy, e-cigarettes are mass-marketed recreational consumer products; they are not medicine
developed to be administered under clinical supervision. Another issue embedded in the debate
over the assessment of e-cigarettes and smoking cessation is whether their effects should be assessed
only among people who are actively using them as part of a smoking cessation attempt or on all

Study OR (95% CI) Weight (%)
Smoking initiation
Barrington-Trimis et al. (2016) 6.17 (3.29, 11.57) 12.4
Leventhal et al. (2015) 1.75 (1.10, 2.78) 15.5
Miech et al. (2016) 4.78 (1.91, 11.96) 8.3
Primack et al. (2015) 8.30 (1.19, 58.00) 2.6
Primack et al. (2016) 8.80 (2.37, 32.69) 5.0
Spindle et al. (2017) 3.37 (1.91, 5.94) 13.5
Wills et al. (2016) 2.87 (2.03, 4.05)) 17.9
Subtotal (I 2 = 60.0%, p = 0.020) 3.62 (2.42, 5.41) 75.2
Current (30 day) smoking

Hornik et al. (2016) 5.43 (2.59, 7.27) 14.5

Unger et al. (2016) 3.32 (1.55, 7.11) 10.3

Subtotal (I 2 = 9.0%, p = 0.295) 4.61 (2.93, 7.26) 24.8
Overall (I 2 = 57.4%, p = 0.016) 3.77 (2.70, 5.27) 100.0
1 2 4 10 20
Odds of smoking (OR)
Figure 2
Ever e-cigarette use among never smokers at baseline quadruples the odds of being a smoker at follow-up.
Meta-analysis is by the authors following Soneji et al. (119). Citations for studies: 15, 65, 79, 88, 102, 103,
121, 133, 142. Note: Weights are from random effects meta-analysis. Abbreviations: CI, confidence interval;
OR, odds ratio.
smokers who use them regardless of motivation. This situation is further complicated because
a major reason that smokers use e-cigarettes is to continue inhaling nicotine in locations where
conventional cigarette smoking is prohibited (e.g., workplaces, public places such as restaurants and
bars, and smokefree homes) (99, 116, 131). Smokefree environments both motivate and support
quit attempts (43, 95, 144, 148). By potentially dulling the effects of smokefree environments,
the real-world use of e-cigarettes could reduce quit attempts and keep people smoking. As more
jurisdictions include e-cigarettes in their smokefree policies and people include them in voluntary
smokefree home rules, this effect will likely be diminished.
As of June 2017, there was only one prospective randomized controlled trial of people using
e-cigarettes to quit smoking (23). This trial, conducted in New Zealand, compared giving patients
nicotine and non-nicotine e-cigarettes with giving them a voucher for nicotine replacement ther-
apy (NRT) that they could redeem at a local pharmacy (usual care in New Zealand). There was
no significant difference in efficacy compared with nicotine patches; both patches and e-cigarettes
showed low efficacy. At 6 months, verified abstinence was 7.3% with nicotine e-cigarettes, 5.8%
among those offered NRT, and 4.1% for those with non-nicotine e-cigarettes. However, because
participants were handed the e-cigarettes and only given a voucher for NRT, these results likely
overstated the efficacy of e-cigarettes and understated the efficacy of well-managed NRT. Another
randomized trial (25) that compared nicotine and non-nicotine e-cigarettes found no consistent
difference in smoking cessation. This study did not have a control group of smokers not using
e-cigarettes, so it does not provide any information about the effects of e-cigarette use per se on
smoking cessation.

These two studies (23, 25) have been the subject of four meta-analyses (40, 58, 71, 87), two
from the Cochrane Collaborative (58, 87), which concluded, with low confidence, that nicotine e-
cigarettes were associated with marginally more quitting than non-nicotine e-cigarettes. Another
meta-analysis (107) pooled the data from these two trials, two cohorts, and two cross-sectional
studies and reached the same conclusion. None of these meta-analyses drew conclusions about
the efficacy of e-cigarettes versus other interventions for cessation because only one of the trials
had a non-e-cigarette comparison (control) group (23).
Most research on the relationship between the use of e-cigarettes and quitting has been from
observational studies that compare cigarette use among smokers who use e-cigarettes with smokers
who do not use e-cigarettes. Although it does not support the same kind of causal conclusions that
an experimental study (i.e., a randomized controlled trial) would, this approach has the advantage
of quantifying the effects of e-cigarettes as actually used, including any indirect effects, such as
discouraging cessation attempts. An analysis of 8 cohort observational studies suggested a possible
reduction in quit rates with the use of e-cigarettes compared with no use of e-cigarettes (OR =
0.74; 95% CI 0.55–1.00) (40).

Kalkhoran & Glantz (70) took a different approach, namely including all 20 available stud-
ies that reported a quantitative estimate of the association between e-cigarette use and having
stopped smoking (2 clinical trials, 15 cohort studies, and 3 cross-sectional studies as of April 2015)
and that had an appropriate control group (70). [They also presented a systematic review of all
38 available studies, regardless of whether they included the information necessary to estimate
the effect of e-cigarette use on smoking cessation (70).] Odds of quitting cigarettes were 28%
lower in those who used e-cigarettes compared with those who did not use e-cigarettes (OR =
0.72; 95% CI 0.57–0.91). This conclusion did not significantly depend on differences in the study
designs: studies of all smokers using e-cigarettes (irrespective of interest in quitting cigarettes)
compared with studies of only smokers interested in cigarette cessation, study design, popula-
tion, comparison group, control variables, time of exposure assessment, biochemical verification
of abstinence, or definition of e-cigarette use. This result indicates that the overall conclusion
that e-cigarettes are associated with less smoking cessation is not an artifact of the study design
methods.
Between April 2015 and June 2017, seven more studies were published on the association
between using e-cigarettes and quitting cigarettes (48, 62, 75, 81, 147, 149, 151). Updating the
Kalkhoran & Glantz meta-analysis (70) to include these studies only slightly changed the pooled
estimate of the effect (0.73, 95% CI 0.59–0.92) (Figure 3). The overall conclusion that smokers
who used e-cigarettes were significantly less likely to stop smoking cigarettes remained.
Four studies (19, 63, 147, 151) did find significantly increased quitting among some e-cigarette
users, suggesting that specific use patterns may be important. One study (19) found that inter-
mittent e-cigarette users (more than once or twice but less than daily use) were less likely to quit
smoking one year later than none-cigarette users, but those who had used e-cigarettes daily for
at least one month were significantly more likely to quit cigarettes. Another study (63) found
that all “cig-alike” users and nondaily tank system users had lower odds of quitting cigarettes,
whereas daily tank system users were significantly more likely to quit. The third study (151) found
that short-term e-cigarette use was not associated with a lower rate of smoking cessation, but
long-term use was. The fourth study (147) found higher quitting smokers specifically using e-
cigarettes as part of a quit attempt in countries with permissive e-cigarette policies (United States
and United Kingdom) than those in countries with restrictive policies (Canada and Australia). In
contrast, in the European Union (including Great Britain, specifically), a study of the relationship
between e-cigarette use and having stopped smoking found less quitting among smokers who used
e-cigarettes (75).

Study OR (95% CI) Weight (%)
Real-world study
Adkison et al. (2013) 0.81 (0.43, 1.53) 3.9
Al-Delaimy et al. (2015) 0.41 (0.18, 0.93) 3.2
Biener & Hargraves (2015), intense 6.07 (1.11, 33.18) 1.3
Biener & Hargraves (2015), intermittent 0.31 (0.04, 2.80) 0.9
Borderud et al. (2014) 0.50 (0.30, 0.80) 4.4
Brown et al. (2014) 1.61 (1.19, 2.18) 5.1
Choi & Forster (2014) 0.93 (0.19, 4.63) 1.4
Christensen et al. (2014) 0.16 (0.07, 0.36) 3.2
Gmel et al. (2016) 0.42 (0.22, 0.78) 3.9
Grana et al. (2014) 0.76 (0.36, 1.60) 3.4
Harrington et al. (2015) 0.90 (0.54, 1.50) 4.3

Hirano et al. (2017) 0.63 (0.41, 0.94) 4.7

Hitchman et al. (2015) 0.83 (0.52, 1.30) 4.5
Kulik et al. (2018), ever use 0.43 (0.32, 0.58) 5.1
Manzoli et al. (2017) 1.25 (0.85, 1.84) 4.8
McQueen et al. (2016) 0.25 (0.09, 0.65) 2.7
Pearson et al. (2015) 0.77 (0.59, 1.00) 5.2
Prochaska & Grana (2014) 1.16 (0.65, 2.05) 4.1
Shi et al. (2015) 0.44 (0.24, 0.79) 4.0
Sutfin et al. (2015) 0.40 (0.21, 0.76) 3.8
Vickerman et al. (2013) 0.50 (0.40, 0.63) 5.3
Zawertailo et al. (2017) 0.51 (0.39, 0.64) 5.3
Zhuang et al. (2016), long term 4.14 (1.50, 11.42) 2.6
Zhuang et al. (2016), short term 0.87 (0.53, 1.43) 4.4
Subtotal (I 2 = 80.0%, p = 0.000) 0.68 (0.54, 0.85) 91.4
Clinical trial
Bullen et al. (2013), randomized 1.26 (0.68, 2.34) 3.9
Hajek et al. (2015), not randomized 1.44 (0.94, 2.21) 4.7
Subtotal (I 2 = 0.0%, p = 0.728) 1.38 (0.97, 1.96) 8.6
Overall (I 2 = 80.8%, p = 0.000) 0.72 (0.58, 0.90) 100.0
0.03 0.1 0.3 1 3 10 30

Odds of having quit smoking (OR)
Figure 3
Smokers who use e-cigarettes are significantly less likely to have stopped smoking than smokers who do not use e-cigarettes, with the
odds of quitting smoking depressed by 27%. Citations for studies: 2, 4, 19, 21, 22, 29, 30, 48, 54, 57, 62, 63, 75, 81, 86, 100, 104, 115,
124, 138, 147, 149, 151. Note: Weights are from random effects analysis. Abbreviations: CI, confidence interval; OR, odds ratio.
These results suggest that e-cigarettes are contributing to the tobacco epidemic by attracting
smokers who are interested in quitting but reducing the likelihood of those smokers to quit
successfully. This effect may be reflected in the fact that in 2015 the number of cigarettes consumed
in the United States was higher than in 2014, the first time cigarette consumption increased since
1973 (139).

HEALTH EFFECTS OF E-CIGARETTES
Are “E-Cigarettes 95% Safer than Cigarettes”?

Influential health organizations in England, including Public Health England (85), the Royal
College of Physicians (105), the Royal Society for Public Health (106), and the National Health
Service (85, 96), have unequivocally stated that e-cigarettes are 95% safer than conventional
cigarettes. This claim originated from a single consensus meeting of 12 people convened by D.J.
Nutt in 2014 (97). They reached this conclusion without citing any specific evidence (32). The
Nutt et al. paper did include this caveat: “A limitation of this study is the lack of hard evidence for
the harms of most products on most of the criteria” (97, p. 224), which has generally been ignored
by those quoting this report (85, 96, 105, 106).
A 2015 editorial in The Lancet (39) identified financial conflicts of interest associated with
Nutt et al. (97), noting that “there was no formal criterion for the recruitment of the experts.”
The Nutt et al. meeting was funded by EuroSwiss Health and Lega Italiana Anti Fumo (LIAF).
EuroSwiss Health is one of several companies registered at the same address in a village out-
side Geneva with the same chief executive, who was reported to have received funding from
British American Tobacco (BAT) for writing a book on nicotine as a means of harm reduction
(66) and who also endorsed BAT’s public health credentials (127). Another of Nutt’s coauthors,
Riccardo Polosa, was Chief Scientific Advisor to LIAF, received funding from LIAF, and reported
serving as a consultant to Arbi Group Srl, an e-cigarette distributor. He also received funding
from Philip Morris International (84, 129). Later in 2015, the BMJ published an investigative
report (51) that raised broader issues surrounding potential conflicts of interest between indi-
viduals involved in the Nutt et al. paper. BMJ provided an infographic illuminating undisclosed
connections between key people involved in the paper and the tobacco and e-cigarette indus-
tries as well as links between the paper and Public Health England via one of the coauthors.
Even so, as of June 2017, the “95% safer” figure remains widely quoted, despite the fact that
evidence of the dangers of e-cigarette use has rapidly accumulated since 2014. This new evidence
indicates that the true risk of e-cigarette use is much higher than the “95% safer” claim would
indicate.
Cancer
Most discussion of the health effects of e-cigarettes has focused on cancer. As noted above, e-
cigarettes deliver lower levels of carcinogens than do conventional cigarettes (50), and lower
levels of carcinogens are found in the bodies of e-cigarette users than are found in smokers (114).
While these observations suggest that e-cigarettes are likely less carcinogenic than conventional
cigarettes, they do deliver carcinogens that can have effects at very low levels following repeat
exposures (32). E-cigarettes deliver the tobacco-specific nitrosamine and potent lung carcinogen
NNK [4-(N-methyl-N-nitrosoamino)-1-(3-pyridyl)-1-butanone, also known as nicotine-derived
nitrosamine ketone] (50, 114). Some evidence indicates that the NNK dose-response curve for
cancer is highly nonlinear, with substantial increases in risk at low doses (60). Known bladder
carcinogens have been detected in the urine of e-cigarette users but not in nonusers (44). In
addition, while nicotine is not a carcinogen, it does promote the growth of blood vessels that
supply tumors and it speeds tumor growth (59).
The fact is, however, cardiovascular and noncancer lung disease kill more smokers (135) than
does cancer (Figure 4), which makes it important to assess the impact of e-cigarette use on these
other diseases.

Cancer
33%
Cardiovascular
and metabolic
48%
Other Pulmonary
1% 18%
Figure 4
Between 1965 and 2015, active and passive smoking killed 21 million people. Although most discussion of
smoking and disease focuses on cancer, cardiovascular disease and metabolic and noncancer pulmonary
disease kill most smokers (134).
Cardiovascular Disease
E-cigarettes adversely impact the cardiovascular system (17, 113). Although the specific role of
nicotine in cardiovascular disease remains debated (16, 17), nicotine is not the only biologically
active component in e-cigarette aerosol. As noted above, e-cigarettes work by creating an aerosol
of ultrafine particles to carry nicotine deep into the lungs. These particles are as small as—and
sometimes smaller than—those in conventional cigarettes (45) (Figure 5). These ultrafine particles
are themselves biologically active, trigger inflammatory processes, and are directly implicated in
causing cardiovascular disease and acute cardiovascular events (101). The dose-response effect
for exposure to particles is nonlinear, with substantial increases in cardiovascular risk with even
low levels of exposure to ultrafine particles (101). For example, exposure to secondhand cigarette
smoke has nearly as large an effect on many risk factors for cardiovascular disease and the risk of
12 × 109 12 × 109
a b
10 × 109 Liquid 1 (high 10 × 109
nicotine content)
Particles/cm3
Particles/cm3
8 × 109 8 × 109
6 × 109 6 × 109 Conventional

cigarette
4 × 109 Liquid 2 (low 4 × 109
nicotine content)
2 × 109 2 × 109
0 0
101 102 103 101 102 103
Particle diameter, D (nm) Particle diameter, D (nm)
Figure 5
Particle number distribution from (a) mainstream aerosol in high and low nicotine content e-liquids and from (b) conventional cigarette
as a function particle size (diameter, D). Adapted from Fuoco et al. (45) with permission from the publisher. Copyright
c 2013 Elsevier
Ltd.

acute myocardial infarction as does being an active smoker (13). In addition, e-cigarettes expose
users to acrolein and other aldehydes (17, 18). Like conventional cigarette smokers, e-cigarette
users experience increased oxidative stress (26, 92) and increases in the release of inflammatory
mediators (26, 61). E-cigarette aerosol also induces platelet activation, aggregation, and adhesion
(64). All these changes are associated with an increased risk of cardiovascular disease.
These physiological changes are manifest in rapid deterioration of vascular function following
use of e-cigarettes. E-cigarette and traditional cigarette smoking in healthy individuals with no
known cardiovascular disease exhibit similar inhibition of the ability of arteries to dilate in response
to the need for more blood flow (26). This change reflects damage to the lining of the arteries
(the vascular endothelium), which increases both the risk of long-term heart disease and an acute
event such as a myocardial infarction (heart attack) (141, 145, 146). Using e-cigarettes is also
accompanied by a shift in balance of the autonomic (reflex) nervous system toward sympathetic
predominance (26, 92), which is also associated with increased cardiac risk (56, 126).
The biological stresses that e-cigarette use imposes on the cardiovascular system are manifest
as an increase in risk of acute myocardial infarction (125). A cross-sectional analysis of data in

the US 2014 and 2016 National Health Interview Surveys revealed that daily e-cigarette use
was associated with increased odds of having suffered a myocardial infarction (OR = 1.79, 95% CI
1.20–2.66; p = 0.004), controlling for conventional cigarette smoking, demographic characteristics
(age, gender, body mass index, family income) and health characteristics (hypertension, diabetes,
and hypercholesterolemia) (125). Significantly, the effect of using e-cigarettes on the odds of
myocardial infarction approached what was found with conventional cigarette smoking (OR =
2.72, 2.29–3.24; p < 0.001) (125).
Lung Disease
As with cardiovascular disease, evidence consistently indicates that exposure to e-cigarette aerosol
has adverse effects on lungs and pulmonary function (31, 91). Repeated exposure to acrolein, which
is produced by heating the propylene glycol and glycerin in e-liquids, causes chronic pulmonary
inflammation, reduction of host defense, neutrophil inflammation, mucus hypersecretion, and
protease-mediated lung tissue damage, which are linked to the development of chronic obstructive
pulmonary disease (94). E-cigarette aerosol also exposes users to highly oxidizing free radicals (49).
Animal studies have also shown that e-cigarettes increase pulmonary inflammation and oxidative
stress while inhibiting the immune system (31).
Consistent with these experimental results, people who used e-cigarettes experienced decreased
expression of immune-related genes in their nasal cavities, with more genes suppressed than
among cigarette smokers, indicating immune suppression in the nasal mucosa (82). E-cigarette
use upregulates expression of platelet-activating factor receptor (PAFR) in users’ nasal epithelial
cells (90); PAFR is an important molecule involved in the ability of S. pneumoniae, the leading cause
of bacterial pneumonia, to attach to cells it infects (adherence). In light of the immunosuppressive
effects observed in nasal mucosa (82), there is concern that e-cigarette use will predispose users
toward more severe respiratory infections, as has been demonstrated in mouse studies (67).
Given these effects, it is not surprising that e-cigarette use is associated with a doubling of the
risk of symptoms of chronic bronchitis among US high school juniors and seniors (OR = 2.02;
95% CI 1.42–2.88) with higher risk associated with higher use; these risks persisted among former
users (83). Similarly, current e-cigarette use was associated with an increased diagnosis of asthma
among Korean high school students (adjusted OR = 2.74; 95% CI 1.30–5.78 among current e-
cigarette users who were never cigarette smokers) (28). E-cigarette users were also more likely to
have had days absent from school due to severe asthma symptoms.

Summary of Health Effects

Although e-cigarettes deliver lower levels of carcinogens than do conventional cigarettes, and
therefore may pose less cancer risk to users (albeit not zero cancer risk), they still expose users
to high levels of ultrafine particles and other toxins that may substantially increase cardiovascular
and noncancer lung disease risk. The similarities between the effects of e-cigarettes and those
of conventional cigarettes on determinants of cardiovascular and lung disease make it likely that
e-cigarettes will impose similar long-term cardiovascular and pulmonary risks as those associated
with conventional cigarettes. Cardiovascular and noncancer pulmonary diseases account for about
two-thirds of smokers’ premature deaths from tobacco-induced diseases (Figure 4), so it would
not be surprising if e-cigarettes impose half (or more) of the overall long-term risks as those from
conventional cigarettes.
USE OF E-CIGARETTES IN SMOKEFREE ENVIRONMENTS

Using e-cigarettes in places where smoking is prohibited (e.g., workplaces, public places such
as restaurants and bars, and otherwise smokefree homes) is one of the reasons that people use
e-cigarettes (99, 116, 131). (This situation is changing as more places include e-cigarettes in their
smokefree policies.) Even though e-cigarettes do not produce any sidestream smoke (the smoke
that comes off the lit end of a smoldering cigarette), they do pollute the air in the form of exhaled
mainstream aerosol from people using e-cigarettes. Nicotine, ultrafine particles, and products of
heating propylene glycol and glycerin are increased in the air where e-cigarettes are being used,
although, as expected, at lower levels than produced by smoking the same number of conventional
cigarettes (12, 34, 46, 112).
As with conventional cigarettes, however, when several people are using e-cigarettes indoors
at the same time, the air can become polluted. For example, levels of fine particulate matter
(PM2.5 ) in a large hotel event room (4,023 m3 ) increased from 2–3 µg/m3 to as high as 819 µg/m3
interquartile range: 761–975 µg/m3 ) when 59–86 people were using e-cigarettes (120). This level
is comparable to a very (conventional tobacco) smoky bar or casino and dramatically exceeds the
US Environmental Protection Agency annual time-weighted standard for PM2.5 of 12 µg/m3
(137).
Evidence has also shown that bystanders absorb nicotine when people around them use e-
cigarettes at levels comparable with exposure to conventional cigarette secondhand smoke (12).
In a study of nonsmokers living with nicotine e-cigarette users, those living with conventional
cigarette smokers, or those living in homes where no one used either product, cotinine (a metabolite
of nicotine) levels in bystanders’ urine were significantly elevated in both the people exposed to
secondhand e-cigarette aerosol and those exposed to secondhand tobacco smoke compared with
people living in aerosol- and smoker-free homes. Interestingly, the levels of elevated urinary
cotinine in the two exposed groups were not significantly different (although the passive smokers
had higher point estimates), despite the fact that the increase in air pollution in the smokers’ homes
was much higher than in the e-cigarette users’ homes (geometric mean air nicotine concentrations
of 0.13 µg/m3 in e-cigarette users’ homes, 0.74 µg/m3 in smokers’ homes, and 0.02 µg/m3 in the
control homes).
On the basis of emerging evidence, in 2014 the American Industrial Hygiene Association (3,
p. 2) concluded that “e-cigarettes are not emission-free and that their pollutants could be of health
concern for users and those who are exposed secondhand. . . .[T]heir use in the indoor environment
should be restricted, consistent with current smoking bans, until and unless research documents
that they will not significantly increase the risk of adverse health effects to room occupants.”

Similarly, in 2016 the American Society of Heating, Refrigeration and Air-Conditioning Engi-
neers (ASHRAE) updated its standard for “Ventilation for Acceptable Indoor Air Quality” to
incorporate emissions from e-cigarettes into the definition of “environmental tobacco smoke,”
which is incompatible with acceptable indoor air quality (10, 11). As of April 2017, 12 US states
and 615 localities had prohibited the use of e-cigarettes in venues in which conventional cigarette
smoking was prohibited (7).
POLICY ISSUES
Initial hopes that e-cigarettes would be both a less toxic competitor to conventional cigarettes and
a help to people who attempt to quit smoking cigarettes (76) have not translated into real-world
positive effects. Instead, e-cigarettes have simply become another class of tobacco products that
are maintaining and expanding the tobacco epidemic.
As the major tobacco companies have moved into, and increasingly dominated, the e-cigarette
market, they are dominating the political and policy-making environments just as they have in
conventional cigarette policy making (33, 78). As they have done to influence tobacco control
policies for conventional cigarettes (132), the large companies often try to stay out of sight and
work through third parties that can obscure their links to the tobacco industry (33). The one
difference from the historical pattern of industry efforts to shape tobacco policy from behind
the scenes is that there are also genuine independent sellers of e-cigarettes and associated users
(so-called vape shops) who are not necessarily being directed by the cigarette companies. These
smaller operators are, however, losing market share to the big tobacco companies (89), and the
real political power is now being exercised by the cigarette companies. The cigarette companies
try to take advantage of the existence of independent players while acting through the industry’s
traditional allies and front groups (33, 42).
Countries have reacted in a variety of ways to the introduction of e-cigarettes in their markets,
ranging from no regulations to a ban on e-cigarettes. The Conference of the Parties to the World
Health Organization Framework Convention (which does not include the United States) has
generally taken a cautious approach to e-cigarettes (140) and has agreed that regulatory measures
need to be implemented to, at a minimum, ensure that e-cigarettes do not worsen the tobacco
epidemic (140). Because of these realities, e-cigarettes should be integrated into tobacco control
policies at all levels of government.
To minimize deleterious health effects, we recommend the following measures:
Prohibit the use of e-cigarettes anywhere that use of conventional cigarettes is prohibited,
including in smokefree homes;
Tax e-cigarettes at levels comparable to cigarettes;
Include e-cigarettes in public education campaigns, particularly communicating the facts
that they are not “harmless water vapor,” do pollute the air, are a gateway to conventional
cigarettes, and are increasingly sold by the same multinational companies that sell conven-
tional cigarettes;
Prohibit the sale of e-cigarettes to anyone who cannot legally buy cigarettes or in any venues
where the sale of conventional cigarettes is prohibited;
Establish a minimum purchase age of 21;
Subject e-cigarettes to the same marketing restrictions that apply to conventional cigarettes
(including no television, radio, or outdoor advertising);
Prohibit cobranding of e-cigarettes with cigarettes or marketing in a way that promotes dual
use;
Prohibit flavored e-cigarettes, particularly menthol, candy, fruit, and alcohol flavors;

Prohibit claims that e-cigarettes are effective smoking cessation aids until e-cigarette com-
panies provide sufficient evidence that, as actually used in the real world, e-cigarettes are
effective for smoking cessation;
Prohibit any health claims about e-cigarette products until and unless they are authorized
by the appropriate regulatory agencies (the FDA in the United States) using scientific and
regulatory standards that account for dual use and effects of e-cigarette use on depressing
smoking cessation; and
Establish quality standards for ingredients and functioning of e-cigarette devices.
Implementing these policies would reduce the likelihood that e-cigarettes will continue to expand
and extend the tobacco epidemic.
THE FUTURE
Because e-cigarettes have been on the market for only a few years, the long-term population
health effects are not known. Nevertheless, it is already clear that e-cigarettes are prolonging and
extending the tobacco epidemic by reducing smoking cessation and expanding the tobacco market
by attracting youth who would otherwise be unlikely to initiate tobacco use with conventional
cigarettes. On the basis of the short-term effects that have been identified to date, e-cigarettes
likely have cardiovascular and noncancer lung disease risks similar to those associated with smoking
conventional cigarettes. Under most reasonable alternative use pattern scenarios, this is a high
enough risk to lead to a net population harm even if some smokers switch to e-cigarettes (47, 69,
80). To minimize harm, e-cigarettes as well as the timing and location of their promotion and use
should be regulated like other tobacco products.
DISCLOSURE STATEMENT
The authors are not aware of any affiliations, memberships, funding, or financial holdings that
might be perceived as affecting the objectivity of this review.
ACKNOWLEDGMENTS
Dr. Glantz’s work was supported in part by grant 1P50CA180890 from the National Cancer
Institute and Food and Drug Administration Center for Tobacco Products. The content is solely
the responsibility of the authors and does not necessarily represent the official views of the National
Institutes of Health or the US FDA. All views by David Bareham are his own and do not necessarily
reflect those of his employer.
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PU39-FrontMatter ARI 12 February 2018 8:40
Annual Review of
Public Health
Contents Volume 39, 2018
Symposium
Commentary: Increasing the Connectivity Between Implementation

Science and Public Health: Advancing Methodology, Evidence

Integration, and Sustainability

David A. Chambers p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1
Selecting and Improving Quasi-Experimental Designs in Effectiveness
and Implementation Research
Margaret A. Handley, Courtney R. Lyles, Charles McCulloch,
and Adithya Cattamanchi p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 5
Building Capacity for Evidence-Based Public Health: Reconciling the
Pulls of Practice and the Push of Research
Ross C. Brownson, Jonathan E. Fielding, and Lawrence W. Green p p p p p p p p p p p p p p p p p p p p p p p p27
The Sustainability of Evidence-Based Interventions and Practices in
Public Health and Health Care
Rachel C. Shelton, Brittany Rhoades Cooper, and Shannon Wiltsey Stirman p p p p p p p p p p p p p55
Epidemiology and Biostatistics
Selecting and Improving Quasi-Experimental Designs in Effectiveness

and Implementation Research
Margaret A. Handley, Courtney R. Lyles, Charles McCulloch,
and Adithya Cattamanchi p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 5
Agent-Based Modeling in Public Health: Current Applications and
Future Directions
Melissa Tracy, Magdalena Cerdá, and Katherine M. Keyes p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p77
Big Data in Public Health: Terminology, Machine Learning,
and Privacy
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Environmental Determinants of Breast Cancer
Robert A. Hiatt and Julia Green Brody p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 113
v
Meta-Analysis of Complex Interventions

Emily E. Tanner-Smith and Sean Grant p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 135
Precision Medicine from a Public Health Perspective
Ramya Ramaswami, Ronald Bayer, and Sandro Galea p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 153
Relative Roles of Race Versus Socioeconomic Position in Studies of
Health Inequalities: A Matter of Interpretation
Amani M. Nuru-Jeter, Elizabeth K. Michaels, Marilyn D. Thomas,
Alexis N. Reeves, Roland J. Thorpe Jr., and Thomas A. LaVeist p p p p p p p p p p p p p p p p p p p p p 169
Social Environment and Behavior

The Debate About Electronic Cigarettes: Harm Minimization or the

Precautionary Principle
Lawrence W. Green, Jonathan E. Fielding, and Ross C. Brownson p p p p p p p p p p p p p p p p p p p p p p 189
Harm Minimization and Tobacco Control: Reframing Societal Views
of Nicotine Use to Rapidly Save Lives
David B. Abrams, Allison M. Glasser, Jennifer L. Pearson,
Andrea C. Villanti, Lauren K. Collins, and Raymond S. Niaura p p p p p p p p p p p p p p p p p p p p p 193
E-Cigarettes: Use, Effects on Smoking, Risks, and Policy Implications
Stanton A. Glantz and David W. Bareham p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 215
Increasing Disparities in Mortality by Socioeconomic Status
Barry Bosworth p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 237
Neighborhood Interventions to Reduce Violence
Michelle C. Kondo, Elena Andreyeva, Eugenia C. South, John M. MacDonald,
and Charles C. Branas p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 253
The Relationship Between Education and Health: Reducing
Disparities Through a Contextual Approach
Anna Zajacova and Elizabeth M. Lawrence p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 273
Environmental and Occupational Health
Building Evidence for Health: Green Buildings, Current Science, and

Future Challenges
J.G. Cedeño-Laurent, A. Williams, P. MacNaughton, X. Cao,
E. Eitland, J. Spengler, and J. Allen p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 291
Environmental Influences on the Epigenome: Exposure-Associated
DNA Methylation in Human Populations
Elizabeth M. Martin and Rebecca C. Fry p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 309
vi Contents
From Crowdsourcing to Extreme Citizen Science: Participatory

Research for Environmental Health
P.B. English, M.J. Richardson, and C. Garzón-Galvis p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 335
Migrant Workers and Their Occupational Health and Safety
Sally C. Moyce and Marc Schenker p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 351
Mobile Sensing in Environmental Health and Neighborhood Research
Basile Chaix p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 367
Public Health Practice and Policy
Commentary: Increasing the Connectivity Between Implementation

Science and Public Health: Advancing Methodology, Evidence

Integration, and Sustainability
David A. Chambers p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1
Building Capacity for Evidence-Based Public Health: Reconciling the
Pulls of Practice and the Push of Research
Ross C. Brownson, Jonathan E. Fielding, and Lawrence W. Green p p p p p p p p p p p p p p p p p p p p p p p p27
The Sustainability of Evidence-Based Interventions and Practices in
Public Health and Health Care
Rachel C. Shelton, Brittany Rhoades Cooper, and Shannon Wiltsey Stirman p p p p p p p p p p p p p55
The Debate About Electronic Cigarettes: Harm Minimization or the
Precautionary Principle
Lawrence W. Green, Jonathan E. Fielding, and Ross C. Brownson p p p p p p p p p p p p p p p p p p p p p p 189
Harm Minimization and Tobacco Control: Reframing Societal Views
of Nicotine Use to Rapidly Save Lives
David B. Abrams, Allison M. Glasser, Jennifer L. Pearson,
Andrea C. Villanti, Lauren K. Collins, and Raymond S. Niaura p p p p p p p p p p p p p p p p p p p p p 193
E-Cigarettes: Use, Effects on Smoking, Risks, and Policy Implications
Stanton A. Glantz and David W. Bareham p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 215
Neighborhood Interventions to Reduce Violence
Michelle C. Kondo, Elena Andreyeva, Eugenia C. South, John M. MacDonald,
and Charles C. Branas p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 253
Mobile Sensing in Environmental Health and Neighborhood Research
Basile Chaix p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 367
Policy Approaches for Regulating Alcohol Marketing in a Global
Context: A Public Health Perspective
Marissa B. Esser and David H. Jernigan p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 385
Contents vii
Problems and Prospects: Public Health Regulation of Dietary

Supplements
Colin W. Binns, Mi Kyung Lee, and Andy H. Lee p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 403
Health Services
Achieving Mental Health and Substance Use Disorder Treatment

Parity: A Quarter Century of Policy Making and Research
Emma Peterson and Susan Busch p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 421
Data Resources for Conducting Health Services and Policy Research
Lynn A. Blewett, Kathleen Thiede Call, Joanna Turner, and Robert Hest p p p p p p p p p p p p p p 437
Designing Difference in Difference Studies: Best Practices for Public

Health Policy Research
Coady Wing, Kosali Simon, and Ricardo A. Bello-Gomez p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 453
How Much Do We Spend? Creating Historical Estimates of Public
Health Expenditures in the United States at the Federal, State, and
Local Levels
Jonathon P. Leider, Beth Resnick, David Bishai, and F. Douglas Scutchfield p p p p p p p p p p p 471
Modeling Health Care Expenditures and Use
Partha Deb and Edward C. Norton p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 489
Promoting Prevention Under the Affordable Care Act
Nadia Chait and Sherry Glied p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 507
Treatment and Prevention of Opioid Use Disorder: Challenges and
Opportunities
Dennis McCarty, Kelsey C. Priest, and P. Todd Korthuis p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 525
Indexes
Cumulative Index of Contributing Authors, Volumes 30–39 p p p p p p p p p p p p p p p p p p p p p p p p p p p 543

Cumulative Index of Article Titles, Volumes 30–39 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 549
Errata
An online log of corrections to Annual Review of Public Health articles may be found at
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E-Cigarettes Use, Effects On Smoking, Risks, and Policy Implications

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PU39CH13_Glantz ARI 26 February 2018 13:16

Annual Review of Public Health

E-Cigarettes: Use, Effects on

Stanton A. Glantz1 and David W. Bareham2

Annu. Rev. Public Health 2018. 39:215–35 Keywords

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WHY PEOPLE USE E-CIGARETTES

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e-cigarette use (%)

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E-CIGARETTES AS A GATEWAY TO CIGARETTE SMOKING

E-CIGARETTES AND SMOKING CESSATION

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Study OR (95% CI) Weight (%)

Current (30 day) smoking

Hornik et al. (2016) 5.43 (2.59, 7.27) 14.5

Unger et al. (2016) 3.32 (1.55, 7.11) 10.3

Overall (I 2 = 57.4%, p = 0.016) 3.77 (2.70, 5.27) 100.0

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0.74; 95% CI 0.55–1.00) (40).

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Study OR (95% CI) Weight (%)

Harrington et al. (2015) 0.90 (0.54, 1.50) 4.3

Hirano et al. (2017) 0.63 (0.41, 0.94) 4.7

Overall (I 2 = 80.8%, p = 0.000) 0.72 (0.58, 0.90) 100.0

0.03 0.1 0.3 1 3 10 30

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HEALTH EFFECTS OF E-CIGARETTES

Are “E-Cigarettes 95% Safer than Cigarettes”?

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6 × 109 6 × 109 Conventional

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as an increase in risk of acute myocardial infarction (125). A cross-sectional analysis of data in

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Summary of Health Effects

USE OF E-CIGARETTES IN SMOKEFREE ENVIRONMENTS

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since 1990. Tob. Control. https://www.doi.org/10.1136/tobaccocontrol-2016-053406

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Commentary: Increasing the Connectivity Between Implementation

Science and Public Health: Advancing Methodology, Evidence

Integration, and Sustainability

Epidemiology and Biostatistics

Selecting and Improving Quasi-Experimental Designs in Effectiveness

Meta-Analysis of Complex Interventions

Social Environment and Behavior

The Debate About Electronic Cigarettes: Harm Minimization or the

Environmental and Occupational Health

Building Evidence for Health: Green Buildings, Current Science, and

From Crowdsourcing to Extreme Citizen Science: Participatory

Public Health Practice and Policy

Commentary: Increasing the Connectivity Between Implementation

Science and Public Health: Advancing Methodology, Evidence

Problems and Prospects: Public Health Regulation of Dietary

Achieving Mental Health and Substance Use Disorder Treatment